Chapter 13 My Nursing Test Banks

A patient arrives in the emergency department with clinical manifestations consistent with a lower gastrointestinal bleed. What should the nurse assess to determine the patients stability?

1. Hemoglobin

2. Hematocrit

3. Vital signs

4. Abdominal rigidity to determine the amount of blood being lost

Correct Answer: 3

Rationale 1: Initially the patients hemoglobin will not illustrate the true blood loss. This is due to a 612 hour delay in intravascular equilibrium related to blood loss.

Rationale 2: Initially the patients hematocrit will not illustrate the true blood loss. This is due to a 612 hour delay in intravascular equilibrium related to blood loss.

Rationale 3: The evaluation of vital signs is the best means to determine the patients stability. Vital signs provide information concerning cardiac and vascular compensation.

Rationale 4: Abdominal rigidity will provide a key to the presence of blood in the abdomen but it does not distinguish the amount of bleeding or the patients level of homeostasis nor does it pinpoint the location.

A patient being treated for a lower gastrointestinal bleed has a capillary refill of 3 seconds, a urinary output of 20 mL/hour, a heart rate of 88, and reports feeling tired. Which finding should the nurse report to the physician?

1. Capillary refill of 3 seconds

2. Urinary output of 20 mL/hour

3. Heart rate of 88 bpm

4. Reports of fatigue

Correct Answer: 2

Rationale 1: A capillary refill of 3 seconds is a normal finding.

Rationale 2: The patients urinary output is indicative of a worsening condition related to hypovolemia and reduced renal perfusion. Urinary output less than 30 cc/hour should be reported to the physician.

Rationale 3: A heart rate of 88 bpm is a normal finding.

Rationale 4: The patient with a lower gastrointestinal bleed will likely report feelings of fatigue related to the blood loss.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed.

Question 3

Type: MCSA

A patient with a serious gastrointestinal bleed arrives in the emergency department and the physician intends to initiate aggressive intravenous therapy. Which solution would the nurse anticipate being used to manage this patients condition?

1. D5 and NS

2. D5W

3. 0.9% NS

4. 0.45% NS

Correct Answer: 3

Rationale 1: Dextrose 5% and 0.9% Normal Saline is a hypertonic solution that is not used for aggressive fluid replacement.

Rationale 2: D5W is a hypotonic fluid that will not stay in the vascular space but rather will be absorbed by the cells. This fluid will not increase intravascular volume.

Rationale 3: Aggressive intravenous management of a patient with gastrointestinal bleeding is done with an isotonic crystalloid solution such as 0.9% NS. This type of fluid will provide intravascular fluid replacement to the depleted circulating fluid. This is done until the patient can be typed and crossed-matched for blood replacement therapy.

Rationale 4: 0.45% NS is a hypotonic fluid that will not stay in the vascular space but rather will be absorbed by the cells. This fluid will not increase intravascular volume.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed.

Question 4

Type: MCMA

A patient, being treated for a gastrointestinal bleed, has the following assessment findings: temperature 97.2F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%. Four hours later the nurse identifies changes in the patients condition. Which changes are associated with complications from management of the condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Temperature 98.2F

2. Heart rate 98 bpm

3. Oxygen saturation 85%

4. Capillary refill of 2 seconds

5. Rales auscultated bilateral bases

Correct Answer: 2,3,5

Rationale 1: This temperature is within normal limits.

Rationale 2: Tachycardia is a manifestation of fluid overload.

Rationale 3: Oxygen desaturation is a manifestation of fluid overload.

A patient with an active lower gastrointestinal bleed has the following vital signs: temperature 97.0 F, HR 68, RR 20, and BP 82/60 mm Hg. The nurse would place the patient in which position?

1. Prone

2. Supine with the legs bent at the knees

3. Supine with the legs raised

4. Side lying with the head of the bed elevated to 30 degrees

Correct Answer: 3

Rationale 1: Positioning the patient prone will not enhance venous return or perfusion to vital tissues and organs.

Rationale 2: Positioning the patient supine with the legs bent at the knees will hinder venous blood return and not increase cardiac output.

Rationale 3: The patients vital signs indicate distress. Placing the patient in a supine position with the legs elevated will promote the venous blood return to the heart. This will help the heart to fill and increase cardiac output and blood pressure.

Rationale 4: Positioning the patient side lying will not enhance venous return or perfusion to vital tissues and organs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed.

Question 6

Type: MCSA

The nurse has been assigned to provide care for several patients on the medical-surgical unit. After reviewing the data exchanged during the shift report, which patient should the nurse plan to assess first? The patient with:

1. An elevated temperature of 99.2F and complaints of nausea

2. Complaints of feelings of fullness and no bowel movement for 2 days

3. A heart rate of 82 bpm, complaints of fatigue, and an episode of coffee ground emesis 4 hours ago

4. Two episodes of melena diarrhea within the past 2 hours

Correct Answer: 4

Rationale 1: The presence of a mildly elevated temperature of 99.2F and complaints of nausea, although uncomfortable for the patient, do not indicate the presence of an immediate problem.

Rationale 2: Feelings of fullness and the lack of a bowel movement are consistent with constipation and warrant action but is not a priority.

Rationale 3: The patients heart rate of 82 bpm signal that the patient is not in immediate danger. The presence of coffee ground emesis may signal slowed or halted bleeding.

Rationale 4: The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse.

A patient being prepared for an endoscopy to diagnose an upper gastrointestinal bleed asks why a nasogastric tube has to be inserted. What would the nurse respond to this patient?

1. You need this to assist with placement of the ostomy tube.

2. The nasogastric tube will assist in the removal of blood clots that may limit the physician in seeing your esophagus.

3. Your physician has left orders for placement of the tube.

4. The tube will reduce the likelihood of you vomiting during the procedure.

Correct Answer: 2

Rationale 1: The nasogastric tube is not used to assist with placement of the ostomy tube.

Rationale 2: The nasogastric tube may be utilized to reduce blood and aid removal of clots that might hinder observation by the physician during the test.

Rationale 3: This response does not meet the patients request for information.

Rationale 4: Vomiting is not managed by a nasogastric tube during this procedure. A local anesthetic spray is applied to the back of the throat before the procedure to reduce gagging and vomiting.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-6: Discuss the importance of endoscopy in the care of the patient with gastrointestinal bleeding.

Question 8

Type: MCSA

A patient recovering from a colonoscopy reports abdominal pain of 4 on a 5 point scale. The patients abdomen is rigid and vital signs are T 99.2, HR 94, R 28, and BP 98/69. What initial action by the nurse is indicated?

1. Assist the patient to turn to aid in relieving the flatus buildup.

2. Continue to observe the patient for additional changes in 15 minutes.

3. Notify the physician.

4. Medicate the patient for discomfort.

Correct Answer: 3

Rationale 1: The patient may experience flatus after a colonoscopy but this would not cause abdominal rigidity or cause pain to be rated 4 on a 5 point scale.

Rationale 2: Taking no action is negligent of the nurse. These findings indicate there is a complication present that needs immediate intervention.

Rationale 3: The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the physician.

Rationale 4: Medication for pain may be necessary but the priority action is notification of the physician.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-6: Discuss the importance of endoscopy in the care of the patient with gastrointestinal bleeding.

Question 9

Type: MCSA

A patient prescribed pantoprazole (Protonix) asks the purpose of the medication. Which response by the nurse is most appropriate?

1. The medication will stop the stomach bleeding.

2. The medication will provide a protective coating to your gastrointestinal system.

3. The medication is used to reduce the acid in your gastric secretions and stabilize the clot to prevent further bleeding.

4. The medication will eliminate any potential gastrointestinal infection you may have.

Correct Answer: 3

Rationale 1: This medication does not stop gastrointestinal bleeding.

Rationale 2: This medication will not provide a protective coating to the gastrointestinal system.

Rationale 3: Pantoprazole (Protonix) is a proton pump inhibitor. Aggressive PPI treatment is used to maintain the gastric pH between 6.0 and 6.5 and is recommended to promote clot stability.

Rationale 4: The management of H. pylori infection is treated with pantoprazole (Protonix) and the use of antibiotics.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed.

Question 10

Type: MCSA

A patient being admitted to determine the presence of an upper gastrointestinal bleed does not believe the diagnosis because of the absence of pain. How would the nurse respond to this patient?

1. Some patients have a high pain tolerance and are able to handle the condition better than others.

2. Pain is not a typical symptom of this condition.

3. You should share this with your physician next time you see him.

4. You must be in the early stages of the disease because pain does not occur until later.

Correct Answer: 2

Rationale 1: Pain tolerance may have little to do with the absence of pain with this disorder.

Rationale 2: The majority of upper gastrointestinal bleeding is painless.

Rationale 3: The patient should share any concerns with the physician but this response does not address the patients comment.

A patient with symptoms consistent with pancreatitis reports feeling ill for the past week. Which diagnostic test will provide the most definitive diagnosis of pancreatitis?

1. Erythrocyte sedimentation rate

2. Serum lipase

3. Serum amylase

4. Complete blood count

Correct Answer: 2

Rationale 1: The erythrocyte sedimentation rate is used to assess for the presence of inflammation but is not specific to pancreatitis.

Rationale 2: The patient indicates that the illness has lasted for a week. The serum lipase results are more sensitive and will be most beneficial given the delay in seeking treatment. The serum lipase results will remain elevated for up to 14 days.

Rationale 3: Serum amylase alone is not specific for pancreatitis as it will become elevated with other conditions.

Rationale 4: A complete blood count will reflect the presence of infection but will not be specific for pancreatitis.

The nurse is caring for a patient with severe pancreatitis. Which intravenous fluid would the nurse anticipate providing to this patient?

1. D5W

2. Lactated Ringers

3. D51/2NS

4. 0.9% NS

Correct Answer: 4

Rationale 1: D5W is a hypotonic fluid that does not increase intravascular volume. It expands intracellular volume.

Rationale 2: Lactated Ringers may be isotonic but is contains potassium, which may be harmful to the patient. Also, if the patient is acidotic, the lactate may further contribute to the acidosis.

Rationale 3: D51/2NS is hypotonic and will not contribute to the expansion to intravascular volume.

Rationale 4: The preferred intravenous solution for replacement during an episode of pancreatitis is 0.9% NS. The life-threatening manifestation of pancreatitis is hypovolemic shock because the patient becomes intravascularly depleted and needs isotonic fluid replacement.

A patient with acute pancreatitis is concerned about becoming addicted to the morphine prescribed for pain management. What response by the nurse is appropriate?

1. You must only take the medication when the pain is intolerable.

2. You may want to consider Demerol to manage your pain because it is less strong.

3. Addiction during this period of acute pain is not likely.

4. Addiction is a very real concern and should be considered when requesting medication.

Correct Answer: 3

Rationale 1: Waiting until the patient is unable to tolerate any additional pain would be inefficient in managing this disorder. Once the acute period of pain has passed, the patient may be managed with nonsteroidal anti-inflammatory medications.

Rationale 2: Demerol is not currently recommended as highly as morphine in the management of pancreatitis. There is better pain control with morphine.

Rationale 3: The use of narcotic analgesics during periods of acute pain is unlikely to result in addiction. Prompt pain management is a key to care of this disorder.

Rationale 4: During times of intense pain, there is little to no risk of addiction as the medications block the pain receptors in the brain.

A patient with acute pancreatitis asks for something to eat. Which response by the nurse is most appropriate?

1. Your physician will likely allow you to eat when the vomiting has subsided.

2. You will be able to have a liquid diet within a week.

3. Once your pain is in control and if your bowels are functioning normally, you will likely be able to begin a soft diet.

4. During this time, you will have to get your nutrition from tube feedings.

Correct Answer: 3

Rationale 1: Vomiting is a concern but not the greatest determinant of when eating will be allowed.

Rationale 2: Unless the patients GI symptoms prevent him from eating, oral feedings should be considered within 2472 hours.

Rationale 3: Dietary intake is typically resumed once the abdominal pain is in control, use of opiates is no longer needed, there is no anorexia, and bowel sounds have returned. New data suggests that initiating feeding with a low-fat soft diet is safe and can reduce hospitalizations as compared to a clear liquid diet

Rationale 4: Tube feeding is used for moderate to severe pancreatitis and if the patient cannot tolerate oral nutrition.

The nurse is assembling the equipment needed to begin caring for a patient with a gastrointestinal bleed who is hemodynamically unstable. What size of intravenous catheter would the nurse choose?

1. 22-gauge 2-inch angiocatheter

2. 18-gauge 1-inch angiocatheter

3. 22-gauge butterfly

4. 20-gauge 2-inch angiocatheter

Correct Answer: 2

Rationale 1: Smaller gauge, longer catheters will slow administration time of the fluid. The lumen of this IV access device do not allow for large and rapid amounts of fluid to be administered. If it is used, there is too much pressure and the vein may infiltrate.

Rationale 3: This size catheter would not be adequate to administer large volumes of intravenous fluids.

Rationale 4: The length of the catheter would not be adequate to administer large volumes of intravenous fluids.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed.

Question 20

Type: MCSA

A patient with an active gastrointestinal bleed has the following vital signs: BP 80/50 mm Hg, HR 102 bpm, RR 24, and oxygen saturation of 80%. The physician is writing orders for a blood transfusion to be provided at this time. What component of blood will the nurse anticipate the physician to order?

1. Whole blood

2. Packed red blood cells

3. Platelets

4. Fresh frozen plasma

Correct Answer: 2

Rationale 1: Whole blood may be ordered in an emergent situation while awaiting cross-matched blood.

Rationale 2: Patients who are hemodynamically unstable and have had considerable blood loss will require blood transfusions of packed red blood cells. Packed RBCs are preferred as this replaces the lost red blood cells, which will help improve oxygenation. The plasma will help expand volume.

Rationale 3: Platelets are not indicated at this time with this situation.

Rationale 4: Fresh frozen plasma is not indicated at this time with this situation.

A patient, being treated for acute gastrointestinal bleeding, is receiving 0.9% normal saline at 200 mL/hour through two large-bore IVs. What assessment finding would the nurse report immediately to the physician?

1. Crackles in both lung bases

2. Urinary output of 50 mL in 1 hour

3. Capillary refill of less than 2 seconds

4. Approximately 200 mL of coffee ground emesis

Correct Answer: 1

Rationale 1: Crackles on auscultation of the lungs suggest fluid overload and should be immediately reported to the physician.

Rationale 2: Urinary output of 50 mL/hour indicates the fluid volume resuscitation has been successful and that renal perfusion has been maintained.

Rationale 3: A capillary refill of less than 2 seconds is a normal finding indicating adequate perfusion.

The nurse is assessing the effectiveness of pain management with morphine sulfate through a PCA pump in a patient with acute pancreatitis. Besides the patients verbal response to the pain scale, what objective assessment findings indicate that the patients pain level is decreasing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure increase

2. Slow, easy respirations

3. Pulse decrease

4. Facial grimacing

5. Blood pressure decrease

Correct Answer: 2,3,5

Rationale 1: An increase in blood pressure is a sympathetic response to pain and anxiety.

Rationale 2: Respiratory rate will decrease to normal levels when pain is controlled.

Rationale 3: The pulse decreases due to the decrease in pain and anxiety.

Rationale 4: Facial grimacing is usually noted when pain is still present.

Rationale 5: Pain control can be evidenced by a decrease in blood pressure due to decreased pain.

A patient, admitted to the ICU with a diagnosis of acute pancreatitis, is prescribed pain medication through a PCA pump. What will the nurse include when teaching the patient and family about the proper use of the pump?

1. The patient should only use the PCA pump when the pain is severe.

2. The family may help by pushing the button when they feel the patient is in pain.

3. The PCA allows the patient to administer smaller amounts of pain medication more frequently, which helps to get more effective pain relief.

4. The PCA delivers pain medication every time the button is pushed.

Correct Answer: 3

Rationale 1: The patient should be taught to use the PCA pump at the start of pain. Pain is easier to control when it is less severe. Waiting to use the pump will make it difficult to achieve adequate pain control.

Rationale 2: The PCA should only be administered by the patient in order to prevent accidental overdosing.

Rationale 3: PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief.

Rationale 4: The PCA does have a dose and time lockout to help prevent an overdose of medication.

A patient with an upper gastrointestinal bleed asks why an endoscopy needs to be done. What would the nurse respond to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It will identify where the bleeding is coming from.

2. So the doctor can possibly stop the bleeding by injecting a medication into the area.

3. The doctor may be able to stop the bleeding by sewing up the area that is bleeding.

4. To figure out how much blood you will need to receive.

5. To identify which antibiotics to prescribe for your treatment.

Correct Answer: 1,2,3

Rationale 1: The purpose of an endoscopy in patients with an acute GI bleed is to establish the site and etiology of the bleed.

Rationale 2: During an endoscopy for upper gastrointestinal bleeding, injection therapy can be done to stop the bleeding. Through direct visualization, the site may be injected with a variety of agents to sclerose, vasoconstrict, or cause a tamponade effect.

Rationale 3: Mechanical techniques to control gastrointestinal bleeding include the use of endoclips. These clips achieve hemostasis by compressing the tissue together. Its action is similar to that of a surgical stitch. Depending on the situation, multiple clips may be applied.

Rationale 4: An endoscopy is not done to determine the amount of blood replacement the patient needs.

Rationale 5: An endoscopy is not done to identify antibiotics to aid in the treatment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-6: Discuss the importance of endoscopy in the care of the patient with gastrointestinal bleeding.

Question 32

Type: MCMA

A patient is surprised to learn the diagnosis of pancreatitis. Which risk factors should the nurse be certain to ask about during the assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Frequency of alcohol intake

2. History of gall stones

3. List of current medications

4. History of smoking

5. History of peptic ulcer disease

Correct Answer: 1,2,3,4

Rationale 1: Excessive alcohol use is a common risk factor for acute pancreatitis.

Rationale 2: Gallstone disease is a common risk factor for acute pancreatitis.

Rationale 3: Medications can cause acute pancreatitis although it is less common.

Rationale 4: Smoking is an independent risk factor in the development of acute pancreatitis.

Rationale 5: Peptic ulcer disease is not a risk factor for the development of acute pancreatitis.